ImportanceAnkle sprains are the most commonly occurring musculoskeletal injury. Reconstruction of the lateral ligament complex is often required for athletes with recurrent instability, or high-grade acute sprains, in order to return to their pre-injury level of sport.ObjectiveThe purpose of this systematic review was to evaluate the spectrum, prevalence and quality of evidence regarding return to sport timeline following lateral ligament surgery.Evidence reviewA search was conducted of Embase and Medline databases from the earliest possible entry to November 2016. Studies reporting a timeline regarding return to play (RTP) following lateral ankle ligament reconstruction were included in this review.FindingsOf 3184 total articles, 20 articles evaluating 489 athletes met the criteria and were included for review. Thirteen of the 20 papers were used to calculate a weighted mean time to RTP of 4.7 months. Overall, both the frequency and quality of RTP criteria and reporting were very low.Conclusions and relevanceThe current review identifies a clear deficiency in the literature pertaining to consistent, meaningful postoperative RTP timeline following lateral ankle ligament repair. Published studies vary considerably in the metrics used for measuring patient-reported outcomes, and very few actually track them. Further studies on outcomes following ankle ligament repair should include clear and consistent metrics for return to sport and level of play. Standardised and reproducible criteria for reporting RTP for athletes will improve the utility and applicability of outcomes data as surgical and rehabilitative techniques continue to advance.Level of evidenceSystematic review of level I–IV studies, level IV.

Background: Acute inversion ankle sprains are among the most common musculoskeletal injuries. Higher grade sprains, including anterior talofibular ligament (ATFL) and calcaneofibular ligament (CFL) injury, can be particularly challenging. The precise effect of CFL injury on ankle instability is unclear. Hypothesis: CFL injury will result in decreased stiffness, decreased peak torque, and increased talar and calcaneal motion and will alter ankle contact mechanics when compared with the uninjured ankle and the ATFL-only injured ankle in a cadaveric model. Study Design: Descriptive laboratory study. Methods: Ten matched pairs of cadaver specimens with a pressure sensor in the ankle joint and motion trackers on the fibula, talus, and calcaneus were mounted on a material testing system with 20° of ankle plantarflexion and 15° of internal rotation. Intact specimens were axially loaded to body weight and then underwent inversion along the anatomic axis of the ankle from 0° to 20°. The ATFL and CFL were sequentially sectioned and underwent inversion testing for each condition. Linear mixed models were used to determine significance for stiffness, peak torque, peak pressure, contact area, and inversion angles of the talus and calcaneus relative to the fibula across the 3 conditions. Results: Stiffness and peak torque did not significantly decrease after sectioning of the ATFL but decreased significantly after sectioning of the CFL. Peak pressures in the tibiotalar joint decreased and mean contact area increased significantly after CFL release. Significantly more inversion of the talus and calcaneus as well as calcaneal medial displacement was seen with weightbearing inversion after sectioning of the CFL. Conclusion: The CFL contributes considerably to lateral ankle instability. Higher grade sprains that include CFL injury result in significant decreases in rotation stiffness and peak torque, substantial alteration of contact mechanics at the ankle joint, increased inversion of the talus and calcaneus, and increased medial displacement of the calcaneus. Clinical Relevance: Repair of an injured CFL should be considered during lateral ligament reconstruction, and there may be a role for early repair in high-grade injuries to avoid intermediate and long-term consequences of a loose or incompetent CFL.

Background: Open metatarsophalangeal (MTP) arthrodesis using locked plates produces good clinical outcomes. However, arthroscopic fusion with new-generation fully threaded compression screws is emerging as an alternative. The purpose of this study was to compare low-profile contoured locked plates with fully threaded compression screws for first MTP fusion, in a biomechanical cadaveric model. Methods: The first rays of 8 matched pairs of fresh frozen cadaveric feet underwent dissection and dual-energy x-ray absorptiometry (DEXA) scanning to measure bone mineral density (BMD). The “plate” group was prepared with cup-and-cone reamers, and fixation of the MTP joint with 1 compression screw and low-profile dorsal locked plate. The matched-pair “screws” group was prepared through a simulated arthroscopic technique, achieving fixation with 2 new-generation fully threaded compression screws. The plantar MTP gap was recorded with an extensometer during 250 000 90-N cyclic loads followed by a single load to failure. Results: The screw group demonstrated significantly greater stiffness, 31.6 N/mm (plates) and 51.7 N/mm (screws) ( P = .0045). There was no significant difference in plantar gapping or load to failure, 198.6 N (plates) and 290.1 N (screws) ( P = .2226). Stiffness and load to failure were highly correlated to BMD for the screw group, r =0.79 and r = 0.94, respectively, but less so for the plate group, r = 0.36 and r = 0.62, respectively. The maximum metatarsal head height measured on the lateral view was strongly correlated with load to failure for both the plate- and screw-only groups ( r > 0.9). Conclusion: These data demonstrate that hallux MTP arthrodesis utilizing fully threaded compression screws had similar plantar gapping and load to failure when compared with the low-profile locking plate, but with significantly more stiffness. These results support an increased role of fully threaded screws for MTP arthrodesis using either the arthroscopic or open technique. However, with decreased BMD plate fixation may remain the better fixation choice. Clinical Relevance: Our data suggest that with regard to construct stability, fully threaded headless compression screws may be just as effective as low-profile locking plates, but BMD and MTP joint fluoroscopic measurements should be considered in the decision-making process for fixation.

Purpose To assess the impact on ankle stability after repairing the ATFL alone compared to repairing both the ATFL and CFL in a biomechanical cadaver model. Methods Ten matched pairs of intact, fresh frozen human cadaver ankles (normal) were mounted to a test machine in 20.0° plantar flexion and 15.0° of internal rotation. Each ankle was loaded to body weight and then tested from 0.0° to 20.0° of inversion. The data recorded were torque at 20.0° and stiffness, peak pressure and contact area in the ankle joint using a Tekscan sensor, rotation of the talus and calcaneus, and translation of the calcaneus using a three‐dimensional motion capture system. Ankles then underwent sectioning of the ATFL and CFL (injured), retested, then randomly assigned to ATFL‐only Broström repair or combined ATFL and CFL repair. Testing was repeated after repair then loaded in inversion to failure (LTF). Results The stiffness of the ankle was not significantly increased compared to the injured condition by repairing the ATFL only (n.s.) or the ATFL/CFL (n.s.). The calcaneus had significantly more rotation than the injured condition in the ATFL‐only repair (p = 0.037) but not in the ATFL/CFL repair (n.s.). The ATFL failed at 40.3% higher torque than the CFL, at 17.4 ± 7.0 N m and 12.4 ± 4.1 N m, respectively, and 62.0% more rotation, at 43.9 ± 5.6° and 27.1 ± 6.8°, respectively. Conclusions There was a greater increase in stiffness following combined ATFL/CFL repair compared to ATFL‐only repair, although this did not reach statistical significance. The CFL fails before the ATFL, potentially indicating its vulnerability immediately following repair. Level of evidence III, case–control therapeutic study.

torque of ATFL. Thus, a patient's inherent laxity or stiffness is likely a meaningful contributor to strength after repair. The CFL fails before the ATFL, potentially indicating its vulnerability immediately following repair. Restoring the CFL likely plays a relevant role in lateral ligament repair, however sufficient time for ligament healing should be allowed before inversion stresses are applied.